470 23 November 1968 Leading Articles
Br Med J: first published as 10.1136/bmj.4.5629.470 on 23 November 1968. Downloaded from http://www.bmj.com/ on 12 June 2021 at India:BMJ-PG Sponsored. Protected by copyright.
harvesting the allantoic fluids. Ten years ago the virus was
inactivated with formaldehyde and little attempt was made
to purify the product. But technical developments during
the last five years have contributed greatly to the purity of
the vaccine, and turbid fluids have been replaced by slightly
opalescent virus suspensions. The egg proteins are removed
during the purification processes, and vaccines available today
contain only traces of material likely to sensitize the patient.
Indeed, an upper limit has been placed on the quantity of
protein nitrogen allowed in the vaccine. Nevertheless, since
the virus is grown in hens' eggs the vaccine is best not given
to persons with a history of allergic disease, in particular of
sensitivity to hens' eggs. It is most unlikely that a normal
person would have an allergic reaction to the influenza
vaccines available this winter, and highly improbable that
anyone would become sensitized to hens' eggs by being given
a single dose of vaccine. On balance the protection given
by influenza vaccine far outweighs the risk of reactions
occurring in normal non-allergic people.
Squatting in Fallot's Tetralogy
Children with the tetralogy of Fallot soon discover the
symptomatic relief obtained by squatting after exercise.
Indeed, the trick is probably usually learnt in infancy when
they adopt a knee-chest posture. Helen Taussig' was the first
to give a full description of the phenomenon of squatting, and
it is particularly interesting that, in speculating about the
mechanism of relief given to patients in this way, she quoted
the words of a 10-year-old patient, " It cuts off the circulation
to my legs and increases the circulation to my lungs." Since
that time there has been considerable controversy about the
exact way in which squatting affects the circulation in these
patients. W. F. Hamilton and his colleagues2 emphasized
the importance of the rise in systemic vascular resistance that
occurs during squatting, claiming that this would increase the
relative flow into the pulmonary artery. They also stated,
without clear evidence, that squatting increased the systemic
venous return, and subsequently other authors`5 have argued
on similar lines. Nevertheless, L. Brotmacher,8 using
plethysmography and oximetry, concluded that squatting
actually decreased the venous return from the legs, though
he was unable to measure venous flow directly.
Recently W. G. Guntheroth and his colleagues have
measured directly the flow in the inferior vena cava in
patients with Fallot's tetralogy. They have confirmed
Brotmacher's conclusion about diminished venous return
during squatting, and have also shown that there is a sustained
decrease in flow in the inferior vena cava in the knee-chest
position adopted during squatting after exercise. This is
accompanied by a rise in systemic arterial pressure and a
Taussig, H. B., Congenital Malformation of the Heart, 1960, Vol. 2,
2nd ed., p. 23. Cambridge, Mass.
2 Hamilton, W. F., Winslow, J. A., and Hamilton, W. F., jun., 7. clin.
Invest., 1950, 29, 20.
Nadas, A. S., Pediatric Cardiology, 1963, 2nd ed., p. 353. Philadelphia.
4 O'Donnell, T. V., and McIlroy, M. B., Amer. Heart 7., 1962, 64, 347.
Sharpey-Shafer, E. P., Brit. med. 7., 1956, 1, 1072.
Brotmacher, L., Brit. Heart 7., 1957, 19, 567.
Guntheroth, W. G., Mortan, B. C., Mullins, G. L., and Baum, D.,
Amer. Heart 7., 1968, 75, 313.
DIBALJURN
rise in arterial oxygen saturation, which had fallen to low
levels during exercise.
Guntheroth and his co-workers point out that these
phenomena may be understood by considering what has been
happening during the exercise immediately preceding
squatting. A large oxygen debt has built up, the muscle
vascular beds are dilated and remain so after exercise, and
there is increased extraction of the available oxygen locally,
so that oxygen saturation of the venous blood is further
reduced. Since in Fallot's tetralogy some of the venous
return to the right heart passes directly into the aorta, any
reduction in the venous oxygen saturation leads directly to a
reduction of the arterial saturation as well. The vasodilatation
in the exercised limbs lowers the total systemic vascular
resistance, and hence there is also a fall in blood pressure.
Squatting helps to counteract these effects in two main ways.
Firstly, by diminishing the blood flow to the legs it helps to
maintain the peripheral vascular resistance, and hence more
of the cardiac output is directed into the lungs. Secondly,
by allowing the oxygen debt after exercise to be paid off over
a longer period it corrects the precipitous fall in arterial
oxygen saturation that has accompanied exercise. Helen
Taussig's patient was right.
Racial Harmony
Last week Mr. Enoch Powell again spoke on racial issues in
a manner apt to inflame opinion on problems that above all
at this time need dispassionate thought. His views have
evoked energetic public discussion, and it is not the task of
the B.M.7. to add to it. But the subject of his speech, race
relations, is something that concerns the medical profession,
for the humane nature of medicine and its international con-
nexions make it stand as plainly opposed as could be to
racial prejudice and conflict.
In one sense this goes without saying. The public face of
medicine in Britain has always been firmly set against any
kind of discrimination. But from time to time the B.M.7.
office does receive letters from doctors who believe they have
been unfairly treated because of their colour. It should be
emphasized that such complaints are rare: it is simply
regrettable that they should have any cause for utterance at
all. Nor is it always certain that the treatment of which a
reader may complain had anything to do with his colour or
race as such, though occasionally that would seem to be the
inescapable inference. Sometimes it would seem to have been
more the result of his simply being a foreigner. And it must
be admitted that, in addition to the usual difficulties a foreigner
may experience in gaining acceptance in any country, a certain
coldness or brusqueness is sometimes noted in Britons when
dealing with a stranger. It springs perhaps from social reserve
and as a cause of offence is wholly unintentional. But it is a
poor companion to that scrupulous politeness and even
positive desire to help on which visitors to these shores some-
times comment with gratitude.
This country owes a debt to the hosts of doctors and nurses,
many of them coloured, who have come here for training or
to find a permanent home. To these colleagues, our fellow
physicians and surgeons, we owe an obligation of working in
complete harmony. Evidence of any departure from it is
rare-and should be absent.